To say the past two years have been a testing time for population wellbeing and mental health would be an understatement. For transformative progress to be made, the focus must be squarely on solutions. Gill Weatherill, partner at DAC Beachcroft, analyses how delivery and service provision is responding to swelling demand.

Everybody in the healthcare sector is acutely aware of the problem and, while the focus is rightly on responding to that problem, it is important first to measure its scale and extent.

Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust has worked behind the scenes with institutions including the University of York and International Centre for Mental Health Social Research in trying to forecast demand, to understand how best to respond. This has included looking at the fallout from natural disasters and conflicts and using that as a basis for modelling.

“The demand is anywhere between 20% and 60% higher, depending on the type of mental health care and treatment, and you have to factor in existing patients suffering worsening conditions on top of the wave of new people experiencing mental health issues. Careful thinking has therefore been required to formulate our response,” says Brent Kilmurray, TEWV Chief Executive.

Part of that response is to ‘move upstream’ and think in a more preventative manner. For TEWV, this has involved a range of new activities, from working in schools to greater investment in digital platforms like Kooth, which has seen a huge increase in log-ons during 2021.

“Those mechanisms are important for us to be able to steer people towards access and support, in a way that is available to them earlier on, as wellbeing concerns begin to surface,” says Kilmurray. “We’ve got to do that more with the general population.”

Getting upstream includes harnessing the benefits of both the environment and the community within which people live. For instance, Kilmurray is chairing a green social prescribing scheme in Humber, Coast and Vale, which uses the natural environment to promote wellbeing. The group and individual activities involved contain work, training and pleasure aspects.

“This is all part of the preventative work being done. We are also building on the work we have been doing with the voluntary and community sector and community groups, or organisations like MIND, to provide different levels of intervention and support for people, so it’s accessible locally and people can get hold of it when and where they need it.”

For mental health, determinants go far beyond healthcare and symptoms or conditions. Providers are therefore thinking more holistically about their response. Teams are being configured to think local, taking into account factors such as employment, welfare, debt advice and financial support.

“Wellbeing recovery has to include working with people to support their entire life journey,” says Kilmurray. “When we think more holistically about the causes of problems, and provide support in other aspects of people’s lives, they have greater stability and bandwidth to be more receptive to treatment.”

Social intervention is a key part of the puzzle when it comes to responding to heightened mental health demand. Better understanding of technology and population health management is game-changing, here, and Kilmurray praises the more “actuarial” way of thinking around social issues rather than medicalising everything. This will prevent demand, as well as promoting recovery.

The drivers for place-based focus that are built into the Health Bill and ICS help in the appreciation for more local, social factors, while Kilmurray says another key change has been the incentives system.

“There is a new sense of realism, thanks to contractual changes and, for instance, moving away from payment by results. This is key to fundamentally transforming things,” says Kilmurray.

Digital drivers

Alongside the explosion of digital health products and solutions seen over the past few years and accelerated further during the pandemic, the digital policy drive is also taking effect. Former Secretary of State Matt Hancock was very keen on promoting digital technology, while it also featured heavily in the Long-Term Plan.

Indeed, Gary O’Hare, Executive Director of Nursing at Cumbria, Northumberland, Tyne and Wear (CNTW) NHS Foundation Trust, says he was in awe of the resilience shown by health and social care staff, but adds that the digital policy drive was also crucial in facilitating that response.

“In the first wave there was a real challenge in delivering our services, but we were able to keep our services open and, really, that was on the back of the digital revolution of the NHS,” says O’Hare, who adds that he was pressing leaders to go even further, and faster.

National and international bodies – from the National Institute for Clinical Excellence recommending digital-first approaches for young people experiencing mental health issues, through to wider messaging on a global scale from the World Health Organisation – are also pushing the sector to maximise the potential of technology.

As a result, end-user adoption and take-up have been strong, with a greater embracing of tools that might previously have been viewed as ‘add-ons’, as well as the emergence of new innovations.

“Digital health has rapidly increased, and people are more readily using those solutions. In fact, 25% more than they were pre-COVID, when we saw about 4 million downloads of digital health technology every day. Now it’s more like 5 million,” says Liz Ashall-Payne, Co-founder and CEO of ORCHA, the leading provider of digital health accreditation and distribution services.

The spike in digital uptake is occurring across all parts of the healthcare system. ORCHA reviews app technology and creates libraries which healthcare professionals use to recommend apps directly to service users, and has seen those recommendations increasing by a staggering 6500%.

“That means more healthcare professionals are recommending these solutions to their patients,” says Ashall-Payne. “We needed this to cater to the rising mental health demand.”

Governance

Key to adoption, and finding the best solutions amidst the telehealth explosion, is satisfying a high level of governance. The inherently risk-averse nature of many healthcare professionals meant that, in the past, there has been a hesitancy around digital health solutions.

“Clinicians probably had, if anything, an overly cautious approach to this. Governance thresholds have stayed the same, but readiness to consider and openness to adoption has improved. Needs-must has opened people’s eyes,” says Kilmurray.

With a stronger appetite for adoption, the role of organisations like ORCHA has never been more critical in assessing quality. Under ORCHA’s review criteria, quality is assessed against four key elements: data privacy, data security, clinical and professional assurance, and usability and accessibility.

Ashall-Payne notes that the overall quality of solutions is less than desirable, with ORCHA research showing that despite the volume of new digital health solutions, only 20% meet quality standards.

“In mental health, 29.3% of products meet the quality criteria. And mental health is a complicated area, encompassing anything from obsessive compulsive disorder (OCD) through to anxiety. In OCD, the volume that meets the quality threshold falls to 5%,” explains Ashall-Payne. “If only 5% meet the necessary requirements, and five million people are downloading these tools daily, we have a huge problem.”

Good solutions are out there, but end users need to know which solutions they are, and have comfort that they not only provide medical support, but do so in a way that is easy to interact with, and which protects data security and privacy. Safety – on all these fronts – is paramount.

This is where regulation comes in. Ted Baker, Chief Inspector at the Care Quality Commission, says CQC is very open to new and different approaches, but warns that technological solutions can have unpredicted effects, so regulator involvement can help to alleviate issues.

“We encourage people to talk to us early on and we can support them in getting things right from the outset,” says Baker. “We don’t just look at services for the care they provide, but crucially are they providing the care the population needs, and can the people who need it, access it? Otherwise you exacerbate inequalities.”

Hybrid approach

Aside from leveraging digital advances, developing and upskilling practitioners is going to be key to transformation. Partly thanks to the pandemic prompting a surge in demand, workforce supply is a challenging issue. The time lag between hiring new talent and preparing them to make an impact must also be kept in mind, so the response must focus on attracting new workers, improving training processes and extending the scope of practitioners.

“We need innovative ways of getting people in and training them, getting their skills and accreditation sorted,” says Kilmurray. “We need to get more creative in skill-mixing and maximising the skillsets we have, so people operate within the boundaries of, but also to the limits of their license, in different roles. This will also create rewarding career paths for people.”

Training is also at the forefront of ORCHA’s thinking. It has frontloaded its account aimed at clinicians with a digital health academy which runs CPD-accredited training.

Clearly, an adequate supply of mental health service provision will be founded in balancing the efficiency and flexibility of ‘digital’ with the trust, experience and appreciation-for-nuance of ‘human’.

The human element is important for both physical and digital healthcare. Physically, there will always be a need and role for people to play in delivering healthcare. But people also play a crucial role as digital ambassadors. Based on a practitioner’s medical experience and trusted relationship with a patients, their considered selection – and promotion – of digital aids is a powerful tool.

“There will always be a want and a need for face to face, but digital allows access for those that want it and frees up space elsewhere. It’s a real win-win. The thorny issue is knowing which ones to trust and avoiding unsafe products,” says Ashall-Payne. “If a clinician recommends a product to you, you are 70% more likely to download it and this is how we activate people to use digital health technology.”

The hybrid of human and digital in healthcare is central to transformation. A measured approach is needed, especially when you consider that modern society often looks to digital to solve everything and be all things to all people. Richard Graham, Clinical Director at digital mental wellbeing organisation Good Thinking, says there is a greater need for respect and curiosity on both the technological and non-technological side.

“It’s like if I try to do some tiling. I can do it, but there is someone who does it better and faster,” says Graham. “In the pursuit of one-stop-shop platforms, this nuance can be overlooked. Revealing Reality talks about the idea that we use smartphones like Swiss Army knives and forget there may be something better which is separate and distinct.”

When the goal is engagement with hard-to-reach communities, one bad experience can prove costly. Poor user experience (UX) on one digital solution can put people off that specific tool but also alienate them from all digital tools, so digital mania has to be kept in check.

In a field of healthcare with such a broad spectrum of variation as mental health, the choice provided by a patient-led approach both caters to, and empowers individuals. In turn, the opportunity to prevent, treat and promote recovery from mental health issues is increased.

“We had a blended model where we had video consultations, we had telephonic support and we maintained face-to-face,” says O’Hare.

Kilmurray echoes this view, saying that “choice is the key in any therapeutic relationship”.

“We’re trying to keep the hybrid approach going and think more sensibly about how we continue to transform, for the benefit of patients and the workforce,” adds Kilmurray.

Mental health is also an area where positive sub-sector transformation will help to drive broader economic recovery and transformation. This comes through obvious channels like care improvement and increased investment in new solutions, but also through acknowledging the impact of wellbeing on productivity and output. Ashall-Payne says there is more to be done in changing mindsets in this regard.

“We do still think in siloes. This isn’t just a health issue and, particularly as mental health issues surge, employers across all sectors have a vested interest because of cost and productivity – they have to support the workforce,” says Ashall-Payne.

Creative thinking

Thinking beyond siloes requires thinking outside the box. In light of rising demand, creative solutions are necessary. Part of this is raising awareness of digital tools while being careful not to exacerbate digital divide problems. Using community assets, including non-healthcare figures from teachers through to religious leaders, will help to bridge this gap and also ensure people are being communicated with in terms they understand. Over time, ‘community assets’ can expand to include patients themselves. This is the thinking behind ORCHA’s testing programme for teenagers to assess already-assessed services and products.

“We must learn from them, in terms of their wants, needs and preferences and, in turn, they can recommend the best solutions for their peers,” says Ashall-Payne. “I don’t know much about SnapChat or TikTok, but teenagers do, and there could be lessons to learn from those platforms, so the input is valuable.”

This creativity of thought is vital if mental health service provision is to rise to the challenge of unprecedented levels of demand.